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Home , Laparoscopy, Peritoneal dialysis

ISSN: 2572-3286

Liu et al. J Clin Nephrol Ren Care 2017, 3:028 DOI: 10.23937/2572-3286.1510028 Volume 3 | Issue 2 Journal of Open Access Clinical and Renal Care

RESEARCH ARTICLE Anesthesia Considerations for Insertion of the Peritoneal Xihui Liu1, Xiaoyan Zuo1, Xueyuan Heng1, Zita Abreu2, Todd Penner3, Lashmi Venkatraghavan4 and Joanne M Bargman2* 1Department of Nephrology, Linyi People’s Hospital, China 2Department of Nephrology, Toronto Western Hospital, University Health Network, University of Toronto, Canada 3Division of , University of Toronto, Canada 4Department of Anesthesia, University of Toronto, Canada *Corresponding author: Joanne M Bargman, Department of Nephrology, Toronto Western Hospital, University Health Network, University of Toronto, 200 Elizabeth Street, 8N-840, Toronto, Ontario M5G 2C4, Canada, Tel: 416-340-4804, E-mail: [email protected]

Abstract Pressure (SBP) in the two groups at the beginning of the anesthesia, but during the surgery, the SBP of GA group Background: is an effective method of im- decreased. There were no significant differences of SPO2 plantation for (PD) . Howev- between the two groups. The mean operating time and ob- er, in many centers around the world, Peritoneal Dialysis servation time in the Post-Anesthesia Care Unit (PACU) of Catheter (PDC) insertions are done using an open surgical the GA group was longer. After arrival in the PACU, the method, associated with greater surgical trauma and longer PACU score in GA group was lower than LA group, but there duration of hospitalization. One of the major drawbacks to was no difference between the two groups at discharge. the acceptance of laparoscopic insertion is the perceived necessity for General Anesthesia (GA) for this procedure. Conclusions: Both local and general anesthesia for lapa- In this study, we have examined methods of anesthesia roscopic catheter implantation is safe and effective. Older for laparoscopic insertion of PD catheters at a major North patients, abdominal (as opposed to pre-sternal) exit sites, American center. co-morbidity with mellitus, and those with higher ASA grade do well with local anesthesia. Methods: This retrospective study includes 245 patients with laparoscopic PD catheter insertion from January 2008 Keywords to July 2013 at the University Health Network in Toronto. The patients were consigned to Local Anesthesia (LA) and Laparoscopic insertion, Peritoneal dialysis catheter, Local General Anesthesia (GA) depending on their co-morbidity anesthesia, General anesthesia, Conscious sedation and risk assessment. The LA patients were given intra- venous conscious sedation with midazolam, fentanyl and Introduction propofol. Hemodynamic fluctuations were managed with small doses of vasopressors or vasodilators during the pro- Peritoneal Dialysis (PD) is becoming increasing- cedure. Nitrous oxide and carbon dioxide pneumoperitone- ly popular and different types of surgical techniques um were used for LA group and GA group respectively. (open, percutaneous, and laparoscopic) have been de- Results: The age, the exit site position of the catheter, the veloped for catheter placement [1]. Open surgery and history of and co-morbidities such as di- especially the percutaneous technique are associated abetes and cardiovascular in the two groups were with poor outcomes and sometimes life-threatening significantly different. complications. In fact, the incidence of omental wrap- All patients tolerated the procedure well. Nearly 45% of the ping, catheter displacement, and intra-abdominal com- patients were given LA, there were more ASA grade IV pa- tients in this group. Ten patients were converted to GA from plications, specifically bowel and bladder perforation, is LA. There were no significant differences in Systolic higher with these two methods [2].

Citation: Liu X, Zuo X, Heng X, Abreu Z, Penner T, et al. (2017) Anesthesia Considerations for Insertion of the Peritoneal Dialysis Catheter. J Clin Nephrol Ren Care 3:028. doi.org/10.23937/2572- 3286.1510028 Received: July 25, 2017: Accepted: August 30, 2017: Published: September 01, 2017 Copyright: © 2017 Liu X, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Liu et al. J Clin Nephrol Ren Care 2017, 3:028 • Page 1 of 5 • DOI: 10.23937/2572-3286.1510028 ISSN: 2572-3286

Laparoscopic implantation of PD catheters has been before discharge from the operating room, duration of shown to have advantages such as less surgical trauma operation, PACU scores at arrival and discharge respec- and decreased formation of adhesions [3,4]. Catheters tively, and observation time in PACU. At the same time, placed by laparoscopic methods have also been report- the most recent laboratory blood tests before the sur- ed to have the best outcomes [5]. The keys to successful gery were also been collected (such as hemoglobin, se- long-term PD catheter functioning after implantation rum albumin, creatinine and Creatinine Clearance (Ccr) are visual confirmation of proper catheter location and as a measure of renal function. All the patients were di- configuration during the implantation process [6]. Lap- vided into Local Anesthesia (LA) and General Anesthesia aroscopy, in addition, provides a relatively noninvasive (GA) groups. method to fully investigate the [7,8]. As a result, laparoscopy is becoming a preferential ap- Anesthesia and surgical technique proach in a growing number of centers. All procedures were performed in the operating However, in China and many other countries, near- room with an anesthesiologist in attendance. After ar- ly all Peritoneal Dialysis Catheter (PDC) insertions are rival in the operating room, an Intravenous (IV) cathe- done using an open surgical method. One of the major ter and all standard monitors (electrocardiogram, non drawbacks to the acceptance of laparoscopic insertion invasive blood pressure, pulse oximetery) were applied is the perceived necessity for General Anesthesia (GA), to the patient. Patients undergoing general anesthesia because of gas into the abdominal cavity were induced with IV propofol (1-2 mg.kg-1), fentanyl produces peritoneal . Given that candidates for PD (1-2 µg.kg-1), and cisatracurium (0.15 mg.kg-1) for tra- catheter implantation are patients with end-stage renal cheal intubation. The maintenance of anesthesia was failure who often have severe coexisting medical prob- with oxygen; air with either sevoflurane or desflurane lems that put them in a high-risk category for general (titrated to age adjusted Minimum Alveolar Concentra- anesthesia [9], the feasibility of laparoscopic implanta- tion (MAC) 0.8-1.1). For patients undergoing procedure tion of PDC under local is worthy of investigation. under LA, sedation was started after the application of the monitors. This consisted of midazolam 0.015 mg/ In order to promote acceptance of laparoscopy, we kg, fentanyl 1-2 ug/kg (and/or) remifentanil (0.01-0.1 have examined anesthesia for laparoscopic insertion of µg.kg-1.min-1) followed by propofol (intermittent bolus PD catheters at a major North American center. of 10-20 mg or continuous infusion at 25-150 -1µg.kg . Patients and Methods min-1), titrated to titrated to the assessment of alert- ness/sedation (OAA/S) scale 3 or 4. All patients in the LA This is a retrospective analysis. Between January group received supplemental oxygen via facemask. He- 2008 and July 2013, 245 consecutive adult patients with modynamic fluctuations were managed with small dos- renal failure underwent laparoscopic placement of peri- es of vasopressors or vasodilators during the procedure. toneal dialysis catheters at Toronto General Hospital have been enrolled. All the laparoscopic PD catheter implantations were done by one designated experienced general , All the patients were referred from the nephrology Local anesthesia was achieved by infiltrating the soft clinic to an experienced surgeon in the tissue and with 1% lidocaine. Nitrous Ox- clinic for careful examination before being decided ide (N O) and Carbon Dioxide (CO ) whether they are the good candidates for laparoscopic 2 2 were used for LA group and GA group respectively, in- placement of PDC. The choice of anesthetic technique flating to a maximum pressure of 12 mmHg. After com- (LA or GA) was determined in consultation with anes- pletion of the surgery, patients were transported first to thesiologist upon looking at different factors including the post-anesthesia care unit. age of the patient, associated medical co-morbidity, pa- tient cooperation, prior abdominal surgery and exit site Statistics location of the PDC. Data are expressed as mean ± standard deviation We accessed the electronic patient records, the or as number of patients. Parametric data were ana- patient charts, the operation records, the anesthet- lyzed using the independent samples t-test. For cate- ic records, and the PACU (Post-Anesthesia Care Unit) gorical data analysis, the chi-square or Fisher exact test records. Collected data for this study included demo- was used. A binary logistic regression model was used graphic data and clinical details, including the patients’ to identify the decisive factors of LA patient selection. age, gender, (BMI), cause of renal dis- Odds Ratios (ORs) and 95% Confidence Intervals (CI) ease, abdominal surgery history, co-morbidities such were calculated. Statistical calculations were performed as Diabetes Mellitus (DM) and using the SPSS software version 17.0. Differences were (CVD), physical status according to the American So- considered significant at p < 0.05. ciety of Anesthesiologists (ASA) classification, type of anesthesia, vital signs of the procedure including at the Results beginning of the anesthesia, at the end of the surgery All patients tolerated the procedure well. Mean age in

Liu et al. J Clin Nephrol Ren Care 2017, 3:028 • Page 2 of 5 • DOI: 10.23937/2572-3286.1510028 ISSN: 2572-3286 the study group was 60.60 ± 16.01 years (range 19 to 92), 154.0 ± 22.5 mmHg). The systolic blood pressure at the and 47.8% of the patients were male. The main causes of end of the surgery decreased in both groups, but it was the renal failure were diabetic nephropathy in 71 patients, lower in GA group than LA group (120.2 ± 17.7 mmHg chronic glomerulonephritis in 42 and in 27 versus 128.9 ± 21.4 mmHg). However, before discharge (Table 1). As shown in Table 2, nearly 45% of the patients from the operating room the systolic blood pressure in- were given local anesthesia with conscious sedation. There creased more in GA group. The average oxygen satura- were more ASA grade IV patients in this group. There were tion (SPO2) which was more than 95% during the proce- no significant differences between two groups in gen- dure was similar in both groups. der, BMI, hemoglobin, serum albumin, Ccr, and the PACU Ten patients in whom surgery was initiated with LA scores when discharged. However, the age, presternal were converted to GA. Reasons for conversion included versus abdominal exit site position, history of previous ab- visceral perforation (gall bladder) in 1 patient, agitation dominal surgery, co-morbidities such as DM and CVD, the and significant involuntary shivering in 4 patients, ex- mean surgery time and the PACU scores when arrival in tensive adhesions in 1 patient, poor oxygenation in 1 two groups were significantly different. patient, abdominal breathing in 1 patient, high pressure At the same time, the vital signs during the proce- and abdominal guarding in 1 patient, and coughing in dure were compared between LA and GA groups (Ta- another two patients. ble 3). There were no significant differences between In two patients the insertion of the PDC was abort- GA group and LA group in systolic blood pressure at the ed because of the complication of the surgery, one with beginning of the anesthesia (155.0 ± 26.2 mmHg versus gall bladder injury mentioned above because of a very tiny and an extremely thin Table 1: The primary disease of the study subjects. which would produce the possibility of an infected field, Primary disease N, % and the other due to extensive adhesions and injury to Diabetic nephropathy 71 (29.0%) Chronic glomerulonephritis 42 (17.1%) the transverse colon during the surgery. Hypertension 27 (11.0%) Obstructive nephropathy 14 (5.7%) Table 3: Comparison of the variation of vital signs between two groups during the procedure. Polycystic disease 12 (4.9%) Lupus nephritis 11 (4.5%) Variable Point 1 Point 2 Point 3 Calcineurin inhibitor toxicity 9 (3.7%) SBP LA 155.0 ± 26.2 128.9 ± 21.4 135.8 ± 25.9 Hereditary Nephritis 8 (3.3%) (mmHg) GA 154.0 ± 22.5 120.2 ± 17.7 146.0 ± 25.7 Failed 7 (2.9%) P value 0.746 0.001 0.003 Amyloidosis 5 (2.0%) LA 98.6 ± 1.2 98.8 ± 1.1 97.7 ± 1.6 SPO (%) Vasculitis 4 (1.6%) 2 GA 98.8 ± 1.0 98.5 ± 1.0 98.0 ± 1.6 Acute kidney injury 3 (1.2%) P value 0.272 0.055 0.194 Tumor of 3 (1.2%) Point 1: The beginning of the anesthesia; Point 2: The end of the Vascular disease 3 (1.2%) surgery; Point 3: The post-operation before discharge from the Unknown 15 (6.1%) operating room; SBP: Systolic Blood Pressure; SPO2: Oxygen Others 11 (4.5%) Saturation; LA: Local Anesthesia; GA: General Anesthesia.

Table 2: Comparison of demographic features and clinical details of two study groups. Parameter GA LA P Value N 140 (57.1%) 105 (42.9%) Age (years; mean ± SD) 57.0 ± 16.9 65.4 ± 13.3 0.001 Gender (Male/Female) 63/77 54/51 0.319 BMI (kg/m2) 27.7 ± 7.5 26.4 ± 5.6 0.121 Exit site position (pre-sternal %) 48 (34.8%) 4 (3.8%) 0.001 Abdominal surgery history (yes %) 80 (57.1%) 46 (43.8%) 0.039 DM (yes %) 49 (35.0%) 56 (53.3%) 0.004 CVD (yes %) 42 (30.0%) 48 (45.7%) 0.012 Renal CrCl (mL/min) 13.9 ± 5.8 13.8 ± 7.9 0.910 Hemoglobin (g/L) 103.8 ± 15.4 104.8 ± 16.6 0.632 Serum albumin (g/L) 35.8 ± 4.8 34.7 ± 5.1 0.097 ASA (III/IV) ( IV%) 98/26 (21.0%) 56/35 (38.5%) 0.005 Mean operating time (min) 72.1 ± 50.5 50.5 ± 21.2 0.001 PACU score (arrival) 9.15 ± 1.14 9.72 ± 0.60 0.001 PACU score (discharge) 9.98 ± 0.15 9.98 ± 0.14 0.851 Observation time in PACU (min) 72.1 ± 50.5 50.5 ± 21.2 0.001 LA: Local Anesthesia; GA: General Anesthesia; SD: Standard Deviation; BMI: Body Mass Index; DM: Diabetes Mellitus; CVD: Cardiovascular Disease; Ccr: Creatinine Clearance Rate; ASA: American Society of Anesthesiologists; PACU: Post-Anesthesia Care Unit.

Liu et al. J Clin Nephrol Ren Care 2017, 3:028 • Page 3 of 5 • DOI: 10.23937/2572-3286.1510028 ISSN: 2572-3286

Table 4: Logistic Regression Analysis of the selected factors In our study, the GA group has more patients with the for LA patients. history of previous abdominal surgery included appen- Variables Adjusted OR 95% CI p value dectomy, Cesarean section, , oophorecto- Age 1.034 1.015, 1.053 0.001 my, hemicolectomy, , , ne- Exit site position 9.341 3.948, 22.103 0.001 phrectomy, previous PDC implantation, repair, DM 0.531 0.305, 0.925 0.025 and renal and transplantations. Previous abdom- ASA Grade 0.566 0.311, 1.028 0.062 inal surgery may result in intra-abdominal adhesions LA: Local Anesthesia; OR: Odds Ratio; CI: Confidence Inter- [17], which may need added procedures during the sur- val; DM: Diabetes Mellitus; ASA: American Society of Anes- thesiologists. gery such as adhesiolysis and omentectomy. Hence, the GA should be given to these patients in order to better Sedation administered to the patients included mid- tolerate the surgery. Indeed, we found that there were azolam in 85%, fentanyl in 79% and propofol in 91%. 9 patients who underwent extensive adhesiolysis during Remifentanil was administered in 38% of those under- the surgery, all under GA. going insertion. There was more co-morbidity in the LA group, a re- Binary logistic regression analysis found that older sult of confounding by indication, since it was elected to age, abdominal exit site, co-morbidity with DM, and use LA because of the higher risk for GA [9]. those with higher ASA grade were the decisive factors Patients in the study are classified as ASA grade III or for LA patient selection (Table 4). Therefore, the choice IV according to the American Society of Anesthesiologists of LA versus GA was not random, but informed by the Physical Status Classification. Unfortunately there were 30 risk factors carried by the patients. missing classifications, due to no note in the anesthesia re- Discussion cord. There are more grade IV patients in LA group; how- ever the GA group have more grade III patients, the ASA One of the major impediments to acceptance of sur- classification evaluates the general health status focused gical laparoscopy as a means for PD catheter implanta- on the perioperative risk [18], the higher grade the more tion has been the necessity for a general anesthetic [10- severe systemic disturbances the patients have, making 12]. Laparoscopy is routinely performed with CO ab- 2 them high-risk candidates for GA [19]. dominal insufflation to create the pneumoperitoneum Our results showed that the patients vital signs ex- in the peritoneal cavity. The insufflated CO2 reacts with the peritoneal surface to produce carbonic . The re- pressed as the systolic blood pressure and the SPO2 were all at normal range, which indicates the procedure sulting irritation causes pain [10,13]. In addition, CO2 is rapidly absorbed across the peritoneal membrane and is safe. may contribute to significant metabolic acidosis and The duration of the procedure was shorter in LA cardiac [14,15], disturbances that are not group than the GA group, because the patients need- well tolerated by high-risk renal failure patients [10]. ed to be intubated and ventilated when given GA, and needed to return to the recovery room after surgery. Alternatively, 2 N O is an inert gas and better toler- ated as an insufflation agent [16], because it produces The LA group had higher PACU scores than GA group neither peritoneal irritation nor the metabolic effects, upon arrival and was similar in two groups (all nearly offering a plausible explanation for absence of pain and 10) when discharged from the PACU, which conform to thus enabling laparoscopy with the patient under local the criteria for discharge. The PACU scores are assessed anesthesia [9,12]. Combined with the mild conscious se- by 5 items including respiration, circulation, conscious- dation which is appropriate to alleviate undue fear and ness, muscle strength, color. The observation time in anxiety, the procedure can be tolerated well without GA the PACU was shorter in LA group, because the patients [10]. in LA group were only given a mild sedation. There were Our study shows that the age in LA group is older only a small number of patients in the study group who than the GA group. One explanation is that the young- initiated LA and were converted to GA in order to make er patients have more abdominal musculature than the the surgery go well, so the two anesthesia methods are older patients, leading to significant guarding when the complementary. pneumoperitoneum was given. In order to relax the In conclusion, the present study, although not ran- abdominal muscle, the GA is more suitable for the pro- domized, shows that both local and general anesthesia cedure. In addition, local anesthesia may pose less of a for laparoscopic catheter implantation is safe and effec- risk compared to general anesthesia in the older patient tive. Nearly 45% of the patients are suitable for local an- with co-morbidity. esthesia with conscious sedation. Older patients, those The patients with exit site position located pre-ster- with more severe systemic disturbances (with higher nally need a longer tunnel, and have more tissue trauma ASA grade), having more co-morbidities, abdominal (as incumbent in the subcutaneous tunneling. Because of opposed to pre-sternal) exit site, and those without pre- the associated pain, the GA is indicated. vious abdominal surgery do well with local anesthesia.

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